Only 8% of the total variation in hospital adherence to a composite of key performance measures for heart failure management was attributable to hospital-level features.
Observational (n=68,772)
Yes
What is the extent of hospital-level variation in adherence to key performance measures for heart failure management?
Only a small proportion of hospital variation in medication prescription after discharge for HFrEF was attributable to hospital-level features, suggesting differences in hospital practices are not a major determinant of prescription variations.
Effect estimate: ICC 8% (95% CI 7%-10%)
OBJECTIVE: Investigation of variations in provider performance and its determinants may help inform strategies for improving patient outcomes. METHODS: We used the National Heart Failure Audit comprising 68 772 patients with heart failure with reduced left ventricular ejection fraction (HFREF), admitted to 185 hospitals in England and Wales (2007-2013). We investigated hospital adherence to three recommended key performance measures (KPMs) for inhospital care (ACE inhibitors (ACE-Is) or angiotensin receptor blockers (ARBs) on discharge, β-blockers on discharge and referral to specialist follow-up) individually and as a composite performance score. Hierarchical regression models were used to investigate hospital-level variation. RESULTS: Hospital-level variation in adherence to composite KPM ranged from 50% to 97% (median 79%), but after adjustments for patient characteristics and year of admission, only 8% (95% CI 7% to 10%) of this variation was attributable to variations in hospital features. Similarly, hospital prescription rates for ACE-I/ARB and β-blocker showed low adjusted hospital-attributable variations (7% CI 6% to 9% and 6% CI 5% to 8%, for ACE-I/ARB and β-blocker, respectively). Referral to specialist follow-up, however, showed larger variations (median 81%; range; 20%, 100%) with 26% of this being attributable to hospital-level differences (CI 22% to 31%). CONCLUSION: Only a small proportion of hospital variation in medication prescription after discharge was attributable to hospital-level features. This suggests that differences in hospital practices are not a major determinant of observed variations in prescription of investigated medications and outcomes. Future healthcare delivery efforts should consider evaluation and improvement of more ambitious KPMs.
Emdin et al. (Tue,) conducted a observational in Heart failure with reduced left ventricular ejection fraction (HFREF) (n=68,772). Guideline-recommended in-hospital care (ACE-I/ARB, beta-blockers, specialist follow-up) was evaluated on Hospital-level variation in adherence to composite key performance measures (Intraclass correlation coefficient) (ICC 8%, 95% CI 7%-10%). Only 8% of the total variation in hospital adherence to a composite of key performance measures for heart failure management was attributable to hospital-level features.